David Yu (2016)
This piece is part of in-Training Mental Health Week.
Card playing has never been my forte — perhaps it’s my inability to compute complex math, or my failure to decipher my opponent’s subconscious tells. Most likely, it’s my abysmal poker face — my facial expression lights up like a Christmas tree whenever I get face cards or immediately slumps with a bad hand. In this way, nine months on the wards — from physically restraining an overdosed meth addict or placing an arterial line in a coding patient — has improved my poker game as much as would a course in game theory or card counting. Since I started my third year, I’ve witnessed four patients die on my service — from pneumonia, traumatic bleed, aortic dissection and liver cancer — and subsequently caught a glimpse of the emotional aspects of patient care that physicians address: insults, gratitude, frustration and bewilderment. During my pediatrics rotation, I experienced my fifth patient death, and this one was harder than any before.
Like poker, medicine has certain rules — patterns of clinical symptoms and lab findings each correlating with a specific spectrum of prognoses that vary in likelihood, the differential diagnosis. Physicians are like seasoned card players, trained to maintain composure and incorporate numerous variables into logical, calculated decisions at what seems like a “dealer’s table” of outcomes. Sometimes, we hedge our bets that the patient will self-resolve, so we elect not to treat; other times, we act conservatively with a battery of tests and pre-emptive therapy. However, in the emotionally-charged world of pediatrics, children, and their usually anxious parents, struggle to make decisions based solely on cold rationale, numbers on a lab report and evidence-based statistics. I’ve had parents, who want antibiotics for very likely viral infections, balk at the suggestion of “wait and see,” want confirmation of whatever they read on WebMD or insist that their child is that “one in a thousand” exception. Resource stewardship is out of the question, as no expense shall be spared for their children.
These challenges become especially salient with patients who have been dealt the lousiest cards in the deck. The story of my patient — let’s call her “Amelia” — could have been part of a Grey’s Anatomy script. She had lost her parents as a toddler, one to cancer and the other to grief, was diagnosed with an exceedingly rare, aggressive sarcoma and was thrust into the maw of evidence-based specialist medicine. Experts spared no expense with chemotherapy, surgery, genetic microarrays, imaging and biopsies, hoping to reverse the odds in her favor. We offered her predictions and statistics for the upcoming cards, but knew in our hearts that we couldn’t get a fresh deck, nor rig the game, nor swap dealers. We told her that “things can turn around” and provided her anti-emetics, narcotics and steroids. Yet, after the dealer flipped over the next cards — the flop, the turn, the river — Amelia has no option but to fold. When I first met her, she had just been transferred from an academic medical center to palliative care.
Nurses would tear up when they spoke about Amelia, and droves of her friends and family would visit every day. However, when I first checked in on her, she wasn’t the child I had envisioned. Amelia had her own poker face around doctors — sullen, reticent and imperturbable — hardened by dozens of procedures and drug regimens. She refused to have a medical student in her room as her priorities were seeing her friends and her Dilaudid PCA. She shrieked and threw fits when her dressings were changed, and at other times, refused any treatment or evaluation altogether: no EKG, no pulse oximetry or no vital signs check. I didn’t enter her room until I was on call that following weekend, when she was making orange slushies for the weekend pediatric staff. The nurse whispered excitedly that “this is one of her good days.” When I entered, Amelia’s room was bedecked with balloons and vases of flowers and littered with handmade signs and stuffed animals. However, neither the fragrance of lilies nor the air humidifier humming in the corner could block out the mingled odors of septic cleaner, soiled sheets and body fluids draining from her chest tube and the Jackson-Pratt drain in her shoulder. Amelia was chatting animatedly about watching Ellen DeGeneres, her favorite TV host as she offered me a slushie in a paper cup, and I saw a glimpse of the cheerful girl who lived before this nightmare of a disease. Afterward, my resident submitted a pitch about Amelia’s urgent condition to the “Contact Ellen” webpage, which spouted the tagline “let Ellen make your dreams come true.” We considered telling Amelia to give her something to look forward to, but decided against it lest we disappoint her in the end. We waited with bated breath nevertheless.
Unlike in television, there was no happy ending. Ellen never responded, and one by one, we started crossing off previously considered interventions: no pleuroperitoneal shunt, no epidural placement, no wound vacuum, no albumin replacement. In the end, the team stopped her IV fluids, choosing dehydration over having her fluid overloaded. Eventually, the plans were made to discharge her home, knowing full well that doing so would be to fulfill her last wish. A physician would visit Amelia’s home each day, not for medical counsel, but as a familiar companion. Within hours of her departure, Amelia’s room was cleaned, the scent of lilies still lingering over the bleach floor disinfectant, and I was busy admitting a new patient. Two days later, Amelia died. When my resident and I heard the news, we exchanged a sigh and a sad shrug of the shoulders before continuing to write orders, chart and research protocols. The funeral happened one week later. The staff dressed in blue that day because it was Amelia’s favorite color. I didn’t shed a tear.
My attending physician at the time was a tall, strapping man, sporting a crooked smile and a Texas drawl, with a penchant for afternoon naps and a dislike for ties. Each day, he arrived in a jovial mood, cracked jokes, called me “hoss,” as befitting his Texas roots, and broke down complex differential diagnoses. I would have never guessed that his teenage son had died in an automobile accident the month prior to my rotation. After taking two weeks off to arrange the donation of his son’s organs and attend the funeral, he came back to work. He weathered the expletive-filled tirades of a young mother barely older than his son was, fielded frantic outbursts from parents arriving at the ER with their comatose infant and confronted recently divorced parents over an intoxicated toddler. Was this ability — putting on his poker face at work and with his personal life — a natural talent of his, or the inevitable product of years in the medical education system?
Medical school excels at teaching this process of controlling emotion and focusing on the mountain of administrative tasks that the Byzantine system of modern health care requires. But what isn’t taught is what to do when you wake up in the nascent hours of the morning alone with your thoughts, grappling with the stockpiled emotions of regret, frustration and raw fear that you misled a patient or overlooked a crucial finding. Some people hit the gym and other hike a mountain; some find relief in a bottle. Ultimately, some deal with it by quitting the game. During my pre-clinical years, my medical school offered “mindfulness” events such as free yoga sessions, brown bag lunch discussions, gym events and dog petting days. To be fair, I rarely attended them — partly out of skepticism and denial, believing that I could handle the academic load fine, and partly because I already had my outlets: swimming, weightlifting, digital art or having Skype sessions with college friends. However, I usually brushed off talking about school stresses — there was no emotional attachment, simply tasks to complete and boxes to check off. Yet, with all that changes throughout clinical rotations, I feel like the time for blowing off steam is becoming higher in demand but shorter in supply. This year, I haven’t received a single wellness email for an event that wasn’t during my clinical work time, or wasn’t geared towards pre-clinical students. In my precious few moments off, usually after the rotation exam, I socialize with classmates, and talk about happier topics or tell tall tales about that teratoma or genetic anomaly we saw instead of discussing patient experiences. Thus, it is important that medical schools reserve time for wellness during clinical years in a setting separate from our evaluation and that doesn’t require a quarterly committee report to the dean. It would be a venue to reveal our cards, to vent our frustrations, question the practice of our superiors and institutions without the fear of dismissal or repercussions and to know that we aren’t facing our darkest thoughts alone.
I’ve been dealt unequivocally good cards in life — I have my health, a supportive family and friend circle, and the beginnings of a meaningful career. But one day, those cards will change — accidents happen, people get sick and die, priorities shift and fortunes disappear. After perfecting my career poker face, I wonder how it will shape me as a person, rather than as a physician — or if the two will become inextricably linked. Will I become like my pediatric attending and stand over a loved one’s sick bed as a professional by nature? Will I break under the cumulative emotional weight of my work, finally becoming too much with the crisis at hand? Wearing my poker face is undoubtedly integral to a career in medicine, but even more important is knowing when to take it off and confronting what lies underneath.
Author’s note: “Amelia’s” foster family graciously gave permission for her story to be shared. If you wish to learn more about her story, please contact the author.
Image credit: digital illustration by the author, David Yu, and inspired by Casino Royale — if only we could wear our white coats with such bravado.